Article Text

PDF
G182(P) The big question: Is documentation of X-rays in the Paediatric department up to standard?
  1. K Oyedokun,
  2. S Chakrabarti,
  3. D Padi
  1. Ormskirk and District General Hospital, Southport and Ormskirk Hospital NHS Trust, Ormskirk, UK

Abstract

Background Proper documentation in medical record is an essential component of quality care and a legal requirement for all medical practitioners1. This audit was designed following learning from a case of missed non-accidental injury in which documentation of X-ray review fall short of the standard set by Royal College of Radiologist (RCR)2.

Aim To determine if documentation of X-ray review in the paediatric department is up to the required standard.

Methods We audited two months’ period of activities in Paediatrics department against 3 RCR2 standards (see Table 1). A specially designed form was used to collect data from the electronic medical records and radiology system of all in-patients who had plain X-ray between July and August 2015.

Results Forty-nine patients’ medical notes were reviewed.

One in 5 of x-ray had no documentation of review in medical notes. One in 5 of X-ray requested from neonatal unit and 3 in 10 of those requested from the children ward have no documentation of review.

Out of the 39 patients who had documentation of their X-ray review, 51% had first review within 4 h and 62% within 24 h of imaging. The time of documentation was not specified in about a third (31%) of the sample.

Forty-seven percent had their final report 2–4 weeks after imaging but 4% did not have a formal report of their X-rays.

Abstract G182(P) Table 1

2 month audited activities in Paediatrics department against 3 RCR2 standards

Conclusion Failure to document X-ray review in 20% of the sample fall short of standard. The average time lag of 2–4 weeks between imaging and radiologist report makes documentation of X-ray review more paramount. Also important is accurate documentation of time of X-ray review including name and status of reviewer.

Statistics from Altmetric.com

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.